Restoration of endodontically

treated teeth :
Answers to important questions

Charles J. Goodacre, DDS, MSD

Professor of Restorative Dentistry
Loma Linda University School of Dentistry
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Do endodontically treated teeth
need crowns?
Summary of Changes After RCT
•  Greater force required to activate
proprioception (can bite harder before
protective mechanism activated). One study
showed 57% higher biting force required to
activate pressoreceptors

•  Some physical properties are not affected

and others are altered such as flexibility
(decreased)

•  Greater cuspal deflection after RCT

Summary of Changes After RCT
•  Greater force required to activate
proprioception (can bite harder before
protective mechanism activated). One study
showed 57% higher biting force required to
activate pressoreceptors

•  Some physical properties are not affected

and others are altered such as flexibility
(decreased)

•  Greater cuspal deflection after RCT

Mandibular Molar Cuspal Deflection
•  Up to 1 µm with intact teeth
Mandibular Molar Cuspal Deflection
•  Up to 1 µm with intact teeth
•  MO cavity preparation causes < 2µm of
movement
Mandibular Molar Cuspal Deflection
•  Up to 1 µm with intact teeth
•  MO cavity preparation causes < 2µm of
movement
•  MOD cavity preparation produces 3 to 5 µm
Mandibular Molar Cuspal Deflection
•  Up to 1 µm with intact teeth
•  MO cavity preparation causes < 2µm of
movement
•  MOD cavity preparation produces 3 to 5 µm
•  Endodontic access preparations produces 7 – 8
µm in the MO group and 12 – 17 µm of
movement in the MOD group (a 2 – 3 fold
increase)
Panitvisai, J Endod 1995;21:57-61
 Clinical Fractures
•  1639 RCT posterior teeth were restored with
amalgam – no cusp coverage

•  Maxillary premolars with MOD amalgams had

the highest fracture rate
–  28% fractured within 3 years,
–  57% fractured after 10 years, and
–  73% fractured after 20 years
Hansen, Endod Dent Traumatol 1990;6:49-55
 Survival of RCT Teeth & The
Presence Of Crowns
•  RCT teeth without crowns lost at 6 times the rate of
those with crowns (did not compare anterior vs.
posterior teeth).

•  2nd molars had appreciably poorer 10 year survival

than all other teeth.

•  Teeth with 2 proximal contacts had significantly longer

survival than teeth with 1 or no proximal contacts.
Aquilino, 2002
 Survival of RCT Teeth & The
Presence Of Crowns
•  116 RCT teeth that were extracted.

•  RCT teeth without crowns were lost after an

average time of 50 months.

•  RCT teeth with crowns were lost after an

average time of 87 months.
Vire, 1991
 Failure of Molars with No Crowns
•  220 molars observed for time periods between 6
mo & 10.2 yrs
 Failure of Molars with No Crowns
•  220 molars observed for time periods between 6
mo & 10.2 yrs
•  101 teeth failed (46%) after 5 years (caries, crack
in tooth or filling, loss of filling, root fracture)
 Failure of Molars with No Crowns
•  220 molars observed for time periods between 6
mo & 10.2 yrs
•  101 teeth failed (46%) after 5 years (caries, crack
in tooth or filling, loss of filling, root fracture)
•  14 of 101 teeth were unrestorable
 Failure of Molars with No Crowns
•  220 molars observed for time periods between 6
mo & 10.2 yrs
•  101 teeth failed (46%) after 5 years (caries, crack
in tooth or filling, loss of filling, root fracture)
•  14 of 101 teeth were unrestorable
•  1, 2, 5 yr survival rates (96%, 88%, 36%)
 Failure of Molars with No Crowns
•  220 molars observed for time periods between 6
mo & 10.2 yrs
•  101 teeth failed (46%) after 5 years (caries, crack
in tooth or filling, loss of filling, root fracture)
•  14 of 101 teeth were unrestorable
•  1, 2, 5 yr survival rates (96%, 88%, 36%)
•  Teeth with maximum tooth structure (like Class I
filling) – 5 yr survival of 78%
Nagasiri, J Prosthet Dent 2005;93:164-170
 Composite Resin & RCT Molars
•  Completely intact except for conservative
access opening

•  Can be successfully restored with composite

resin and no crown
Nagasari, J Prosthet Dent 2005
Crowns
significantly
improved the
success of
endodontically
treated posterior
teeth but did not
improve the
success of
anterior teeth
Sorensen, 1985
 True or False Question
•  Crowns should be placed on all root canal
treated teeth
 True or False Question
•  Crowns should be placed on all root canal
treated teeth

•  False
 True or False Question
•  Crowns should be placed on all root canal
treated teeth

•  False

•  Which teeth require crowns most of the time?

 True or False Question
•  Crowns should be placed on all root canal
treated teeth

•  False

•  Which teeth require crowns most of the time?

•  Posterior teeth
Do posts improve the longevity of
endodontically treated teeth or
enhance strength?
 Intact Anterior Crowns Provide Better
Fracture Resistance Than Posts &
Cores
•  Maxillary incisors, without posts, resisted higher
failure loads than the other groups with posts and
crowns
Pontius, J Endod 2002;28:710-715

•  Mandibular incisors with intact natural crowns

exhibited greater resistance to transverse loads
than teeth with posts and cores
Gluskin, J Endod 1995;21:33-37
 Effect of Posts – Their Purpose
•  In laboratory tests on extracted teeth, posts
either weakened the teeth or had a neutral
effect.
•  There is no clinical data to show posts
strengthen a tooth.
•  Therefore, there is no strengthening effect and
the only function of a post is retention of a core.
 Restorative Material Core
vs
Post and Core
•  Preference for restorative material core (without a
post) whenever it can be properly retained. This
concept works best for molars but can work on
premolars and anterior teeth where sufficient
material bulk can be present.

•  Core retention can be obtained using undercuts,

slots, grooves, boxes, pulp chamber, pins, bonding.
 Amalgam cores

PULP CHAMBER RETENTION

Composite resin cores
With All Core Materials, There
Needs to be Adequate Bulk To
Resist Transverse Fracture.
When The Bulk Is Not There,
Then A Post Is Needed
 True or False Question
•  Posts strengthen teeth.
 True or False Question
•  Posts strengthen teeth.

•  False, except perhaps thin coronal tooth

structure. They weaken roots.
 True or False Question
•  Posts strengthen teeth.

•  False, except perhaps thin coronal tooth

structure. They weaken roots.

•  The main purpose of a post is to retain a core.

 True or False Question
•  Posts strengthen teeth.

•  False, except perhaps thin coronal tooth

structure. They weaken roots.

•  The main purpose of a post is to retain a core.

•  True
 What are the most common
complications associated with posts
and cores?

•  Post loosening (5%)

•  Root fracture (3%)
•  Caries (2%)
•  Periodontal Health (2%)
•  Root perforation (1%)
•  Bent / fractured posts (1%)
•  As with all clinical procedures, we
should focus upon preventing or
minimizing complications
associated with posts and cores.
 Retention & Root Fracture

•  Threaded posts are the most retentive but

clinical study data indicates they reduce tooth
survival by about 10%

•  Parallel posts are more retentive than tapered

posts. Parallel posts have a slightly lower tooth
fracture incidence than tapered posts
 Parallel vs Tapered Posts

•  It appears that prefabricated parallel – walled

posts have some advantages

•  However, some teeth are not well suited for

parallel posts
 Post Form Summary
•  It is generally recommended that
posts not be threaded. However,
threaded posts may be useful in the
presence of short roots that possess
adequate root thickness, where
retention is the primary concern and
cemented posts will not be sufficiently
retentive
 Post Form Summary
•  Parallel – walled cemented posts are
generally preferred over tapered cemented
posts. However, custom cast, tapered
posts are recommended for teeth with
tapered roots and roots with substantial
concavities such as mandibular incisors,
maxillary first premolars and certain molar
roots where preparation of round post
spaces will result in excessive tooth
reduction.
What is the optimal post length?
 Short Posts Increase Stress
•  Standlee, 1972
•  Davy, 1981
•  Peters, 1983
•  Hunter, 1989
•  Standlee, 1992
 Length & Fracture Resistance

•  Increasing length
increases fracture
resistance
Trabert, 1978

• Posts should have maximal length and

therefore extend to the gutta percha.
• How much gutta percha is need for a good
apical seal?
 Amount Of Gutta Percha
•  32 of 88 specimens leaked at 2 mm
Camp, 1983
• Significantly more post-treatment periapical
radiolucencies - < 3 mm
Kvist, 1989
• Most 3 mm specimens leaked
Portell, 1982

• Little leakage at 4 mm
Zmener, 1980; Camp, 1983

• No leakage at 4 mm
Neagley, 1969; Madison, 1984; Raiden, 1994

Due to radiographic angle variations, 5 mm of

radiographic gutta percha should be retained.
 The 5 mm Rule Works For
All Teeth Except Molars
•  Based on perforation
data from preparing
extracted teeth, the post
length should not
exceed a length of 7
millimeters in the
primary canals
Abou-Rass, 1982
 True or False Question
•  Post length is determined by retaining the
amount of apical gutta percha required to
maintain an apical seal
 True or False Question
•  Post length is determined by retaining the
amount of apical gutta percha required to
maintain an apical seal
•  True
 True or False Question
•  Post length is determined by retaining the
amount of apical gutta percha required to
maintain an apical seal
•  True

•  What is the appropriate amount of radiographic

gutta percha that should be retained?
 True or False Question
•  Post length is determined by retaining the
amount of apical gutta percha required to
maintain an apical seal
•  True

•  What is the appropriate amount of radiographic

gutta percha that should be retained?
•  5 millimeters
 Completion Question
•  Molar posts should not extend more
than ____ millimeters apical to the canal
orifice at the base of the pulp chamber
 Completion Question
•  Molar posts should not extend more
than ____ millimeters apical to the canal
orifice at the base of the pulp chamber
•  7 mm
 What is the most
appropriate post diameter?
 Diameter & Root Fracture
•  Large posts increase stress.
Mattison, 1982
Hunter, 1989

• With large diameter posts

(1.5 mm or more), root fracture
increased sixfold for every mm
of decreased root diameter.
Deutsch, 1985

• Posts should not exceed

1/3rd the root diameter.
 Avoiding Excess Diameter
•  Controlling post diameter is best
accomplished by selecting instruments of the
proper size.

•  Appropriate instrument size range is 0.6 to

1.2 millimeters in diameter.
 Peeso
Instruments
•  1 – 0.5 mm
•  2 – 0.7 mm
•  3 – 0.9 mm
•  4 – 1.1 mm
•  5 – 1.3 mm*
•  6 – 1.5 mm*

* Do Not Use
 Peeso
Instruments
•  1 – 0.5 mm
•  2 – 0.7 mm
•  3 – 0.9 mm
•  4 – 1.1 mm
•  5 – 1.3 mm*
•  6 – 1.5 mm*

* Do Not Use
 Gates-Glidden
Instruments
•  1 – 0.4 mm*
•  2 – 0.6 mm
•  3 – 0.8 mm
•  4 – 1.0 mm
•  5 – 1.2 mm
•  6 – 1.4 mm*

* Do Not Use
 Round Burs
•  2 – 0.8 to 1.0 mm
•  4 – 1.2 to 1.4 mm*
•  6 – 1.8 to 2.2 mm*
•  Considerable diameter
variation occurs
between manufacturers

* Do Not Use
 Para-Post Instruments
•  3 – Brown 0.9 mm
•  4 – Yellow 1.0 mm
* Do Not Use
•  5 – Red 1.25 mm
•  6 – Black 1.5 mm*
•  7 – Green 1.75 mm*

4 5 6 7
 Completion Question
•  The diameter of posts should not
exceed ____ of the root diameter
 Completion Question
•  The diameter of posts should not
exceed ____ of the root diameter
•  One-third
 Completion Question
•  The diameter of posts should not
exceed ____ of the root diameter
•  One-third

•  The diameter of posts should range

between ___ and ___ millimeters,
depending on the tooth
 Completion Question
•  The diameter of posts should not
exceed ____ of the root diameter
•  One-third

•  The diameter of posts should range

between ___ and ___ millimeters,
depending on the tooth
•  0.6-1.2 millimeters
Does the use of a cervical
ferrule (circumferential band of
metal that encompasses tooth
structure) help prevent tooth
fracture?
Crown Ferrule

Core Ferrule
 Effectiveness of Ferrules
•  Data indicates ferrules formed as part of the
core are less effective than ferrules created
by the crown engaging tooth structure.

•  Ferrule dimensions greater than 1 mm are

needed to provide the tooth with adequate
resistance to fracture. Therefore, 2.0 mm is
proposed as an appropriate dimension to
optimize resistance to fracture.
 Ferrule Uniformity
•  2 mm uniform crown ferrule was compared with 2
mm non-uniform (only 0.5 mm on the proximal
surfaces).

•  The uniform ferrule produced significantly greater

fracture resistance than non-uniform ferrule but the
non-uniform was better than none.

•  A post and core does not strengthen a tooth but it

also does not weaken a tooth when there is a 2
mm ferrule.
Tan, 2005
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
•  False
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
•  False

•  Ferrules should ideally encompass ___ millimeters of

apical tooth structure.
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
•  False

•  Ferrules should ideally encompass ___ millimeters of

apical tooth structure.
•  Two
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
•  False

•  Ferrules should ideally encompass ___ millimeters of

apical tooth structure.
•  Two

•  Ferrules that encompass 2 mm on all 4 axial surfaces

are the best and when present the negative affect of
a post is counteracted.
 True & False and
Completion Questions
•  Core ferrules are preferred over crown ferrules.
•  False

•  Ferrules should ideally encompass ___ millimeters of

apical tooth structure.
•  Two

•  Ferrules that encompass 2 mm on all 4 axial surfaces

are the best and when present the negative affect of
a post is counteracted.
•  True
P & C Fabrication techniques
•  Direct
•  Indirect
•  Prefabricated
•  Custom cast
Direct Prefabricated Post &
Restorative Material Core

•  One appointment
•  Less expensive
•  Judged to be easier by
many clinicians
 Direct Pattern for Cast Post
& Core
•  Resin or wax pattern
•  With resin, be careful
not to lock pattern into
the tooth
 ParaPost System

•  Five sizes:
•  Five matching color
coded drills:
Brown 0.09 mm
Yellow 1.0 mm
Red 1.25 mm
Black 1.50 mm
Green 1.75 mm
Stainless Steel Parapost &
Composite Resin Core
 Thank You For Your
Kind Attention

Charles J. Goodacre, DDS, MSD

Professor of Restorative Dentistry
Loma Linda University School of Dentistry
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